Practical guidelines for orthopaedic surgeons
management of osteoporosis and fragility fractures
on
the
Introduction
Osteoporosis is defined as a systemic skeletal disease characterised by low
bone mass and micro-architectural deterioration of bone tissue with a
consequent increase in bone fragility and susceptibility to fracture. 1
While primary osteoporosis commonly affects postmenopausal women and
elderly males, a number of risk factors, diseases and medications are
associated with secondary osteoporosis in women and men of all ages.
The most serious consequence of osteoporosis is a fragility fracture defined
by the World Health Organisation (WHO)3 as “a fracture caused by injury that
would be insufficient to fracture normal bone with the result of reduced
compressive and/or torsional strength of bone.” Fragility fractures are very
common in older persons, affecting up to one half of women and one third of
men after age 50 years2. While fractures may occur at any site, the most
common sites are the wrist, spine and hip. These fractures are associated
with significant morbidity and mortality. For example, 20 % of hip fracture
patients die within 1 year of the event. Even more disconcerting is the fact that
50% will never regain the ability to lead an independent life. Although the rate
of hip fracture among men is one third to one half that of women of similar age
in first world countries, the rate in men and women seem to be similar in
developing countries including South Africa. Moreover, the increased mortality
associated with hip fractures is higher in men than in women. 4 Vertebral
fractures are two to three times more prevalent than hip fractures, yet only
about one third of vertebral deformities are diagnosed.. Vertebral fracture can
be extremely painful, debilitating, and frequently associated with loss of
height, postural changes, kyphosis, reduced quality of life and increased
mortality.
The high direct (hospitalisation and surgery) and indirect costs (loss of work
days, post-fracture morbidity, rehabilitation and long term care) of the
management and consequences of vertebral and hip fractures place a
significant burden on health care resources and society.
Despite major advances in the identification, diagnosis and management,
osteoporosis is largely under-recognised and treated. Of even more concern
is that the majority of individuals who have already sustained at least one
fragility fracture are neither evaluated nor treated for osteoporosis. It is
estimated that no more than 1 out of every 10 hip fracture patients are further
evaluated and ultimately treated with bone active drugs.
The role of the orthopaedic surgeon
Recognising the impact and importance of osteoporosis prevention and
management, the World Orthopaedic Osteoporosis Organisation (WOOO),
the American Academy of Orthopaedic Surgeons (AAOS), the British
Orthopaedic Association and the Canadian Orthopaedics Associations,
amongst others, have published guidelines for the evaluation and treatment of
osteoporosis and to dispel the myths of osteoporosis.
Orthopaedic myths 7
Osteoporosis evaluation takes too much time
Prevention is ineffective
Treatment is ineffective
Treatment is difficult
Other doctors will take the responsibility
Treatment impairs fracture healing
Once a fracture has occurred, it is too late
Orthopaedic surgeons are uniquely placed for identifying patients at risk of
osteoporosis and fragility fractures. Patients may present with one or more of
the following:
1. An acute or prior fragility fracture at the wrist, spine or hip.
These patients are at the highest risk of developing future fragility fractures
and should be commenced on bone specific treatment.
 Patients with a non-spine fracture have approximately a two-fold
greater risk for future fractures than do individuals who have not had a
fracture.
 Up to half of patients with a prior vertebral fracture will experience
additional vertebral fractures within 3 years and any fracture within the
first year.
 Compared with individuals with no history of vertebral fracture, a
patient with a prior vertebral fracture has nearly a five-fold increased
risk of future vertebral fractures and a two- threefold increased risk of
hip and other non-vertebral fractures.
2. Diseases/disorders associated with osteoporosis and/or fractures (e.g.
rheumatoid arthritis, ankylosing spondylitis and prolonged immobilization).
3. Osteopenia on routine radiographs
symptoms including backache).
(e.g.done
4. Lifestyle and other risk factors (see tables below).
for musculoskeletal
Factors that identify people who should be assessed for osteoporosis 8
Major risk factors
Minor risk factors
 Age > 65 years
 Rheumatoid arthritis
 Vertebral compression fracture
 Past
history
of
clinical
hyperthyroidism
 Fragility fracture after age 40

Chronic anticonvulsant therapy
 Family history of osteoporotic
fracture (especially maternal
 Low dietary calcium intake
hip fracture)
 Smoker
 Systemic glucocorticoid
 Excessive alcohol intake
therapy of > 3 months duration
 Weight <57kg
 Malabsorption syndrome
 Weight loss >10% of weight at
 Primary hyperparathyroidism
age 25
 Propensity to fall
 Chronic heparin therapy
 Osteopenia apparent on X-ray
film
 Hypogonadism
 Early menopause (before age
45)
Adapted from Brown JP et al Council of the Osteoporosis Society of Canada
Major Risk Factors for Osteoporotic Fractures6
Not
Possibly Modifiable*
Modifiable*
Advanced
Low bone mineral density
age
Female sex
Oral glucocorticoid use
Personal
Recurrent falls
history
of
adult fracture
History
of
Current cigarette use
fracture
in
first-degree
relative
Dementia
Alcoholism
Poor
Estrogen deficiency, including menopause onset before age
health/frailty 45 years
Caucasian or
Lifelong low calcium intake
Asian race
Low body weight
Little or no physical activity
__________________________________________________
* Adapted from Bouxsein ML et al
Diseases and Drugs Associated With an Increased Risk of Generalized
Osteoporosis and/or Fractures in Adults6
Diseases**
Drug Therapies**
Rheumatoid arthritis
Oral glucocorticoids
Type 1 diabetes mellitus
Heparin (high doses or prolonged
use)
Multiple sclerosis
Excess thyroid medication
Nutritional
disorders
(especially Aromatase inhibitors
vitamin D deficiency)
Osteogenesis imperfecta
Tamoxifen
Renal disease
Anticonvulsants
Ankylosing spondylitis
Immunosuppressants
Prolonged immobilization
Testosterone antagonists
**Adapted from Bouxsein ML et al
Guidelines on special investigations
1. Conventional skeletal radiography
Conventional radiographs are useful for the diagnosis of fractures and to
exclude other conditions such as hyperparathyroidism. Radiographs may
also alert the physician to the presence of osteoporosis but are not reliable
since 30-40% of skeletal mass must be lost before osteopenia can be
detected9.
2. Dual Energy X-ray absorptiometry (DXA)
The WHO criteria for diagnosis of osteoporosis are based on the bone
mineral density measurement at the hip and spine. DXA is the gold
standard for the measurement of bone mineral density (BMD) at the spine
and hip due to its accuracy, precision and reproducibility. Indications for
BMD include the presence of a fragility fracture, disorders associated with
osteoporosis, more than one risk factor for osteoporosis, osteopenia on
radiographs and for monitoring of patients on treatment.
3. Biochemical investigations
Limited serological tests are indicated in all patients to exclude causes
of
osteopenia
other
than
osteoporosis
e.g.
primary
hyperparathyroidism, osteomalacia. Usually a serum calcium
(corrected for albumin), phosphate and alkaline phosphatase would
suffice. In subjects with a low bone mass, causes of secondary
osteoporosis should also be excluded employing a full blood count and
sedimentation rate (ESR), serum protein electrophoresis, a serum
creatinine and serum gonadotrophins (LH, FSH) and testosterone
(men) or oestradiol (women where menopausal state is unknown).
Further specialised investigations will be determined by the clinical
examination of the patient.
4.
Biochemical parameters of bone turnover
Biochemical markers of formation and resorption are not routinely
recommended, but have been used to identify patients at risk of rapid
bone loss, those at risk of fracture independent of BMD, help
rationalise the therapy of osteoporosis and to monitor/predict the
response to therapy.
Guidelines on management
Management should include Identification of patients with osteoporosis,
measures to prevent further bone loss and fractures, pharmacological
Intervention for established osteoporosis and follow-up and rehabilitative
measures.
1. Identification
A proactive approach should be taken to identify patients on history and
examination of risk factors for osteoporosis and/or fractures and to institute
further evaluation and treatment. Risk factors for osteoporotic fractures
should not be considered to be independent of one another, they are additive
and must be considered in the context of baseline age and sex-related risks of
fracture. For example, a 55 year old with low BMD is at significantly less risk
than a 75 year old with the same low BMD. A person with low BMD and a
prior fragility fracture is at considerably more risk than another person with the
same low BMD and no fracture. Where appropriate the BMD should be
measured and routine biochemical assessment performed to confirm the
diagnosis of osteoporosis and exclude common secondary causes.
2. Prevention
Preventative therapy plays a major role. The American National Osteoporosis
Foundation10 recommends that all patients:
a) Obtain an adequate dietary intake of calcium (at least 1,200 mg per
day), including supplements if necessary.
b) Institute regular weight-bearing and muscle strengthening exercise to
reduce the risk of falls and fractures
c) Avoid smoking and to keep alcohol intake at a moderate level
d) Correct risks associated with falls such as bad vision
3. Pharmacological Intervention
The ultimate goal in treating osteoporosis is to prevent subsequent fractures.
Randomized, placebo-controlled clinical trials involving large populations of
women with osteoporosis, have demonstrated the anti-fracture efficacy of
several agents, including bisphosphonates (alendronate, risedronate),
hormone therapy, selective estrogen receptor modulators (raloxifene),
calcitonin, parathyroid hormone (teriparatide) and strontium ranelate (protos).
The choice of agent will depend on the patient’s clinical profile, age, presence
of co-morbid conditions, site and severity of bone loss and safety and efficacy
profiles of the various agents.
Evidence of Antifracture Efficacy of agents to treat osteoporosis*2
Fracture Type
Vertebral
Hip
Nonvertebral†
Bisphosphonates
Alendronate (Fosamax)
A‡
A
A
Risedronate (Actonel)
A
A
A
Etidronate
A
C
C
Estrogen replacement therapy (HRT)
A
A
A
SERMs (Raloxifene)
A
C
C
Calcitonin, intranasal (Miacalcic)
A
C
C
Teriparatide (hPTH [1-34]
A
A
A
Calcium and vitamin D Preparations
Vitamin D monotherapy and
C
C
C
analogs
Calcium monotherapy
B
C
C
Vitamin D plus calcium
B
A
A
* Adapted from Mary L Bouxsein, PhD, et al
† Nonvertebral fractures; osteoporotic fractures exclusive of the spine
‡ Also in men
A = convincing evidence of antifracture efficacy, B = inconsistent results, C =
ineffective, or insufficient evidence of efficacy
HRT = hormone replacement therapy, SERM = selective estrogen receptor modulator
Adapted from Bouxsein ML et al
4. Follow-up and rehabilitative measures
Follow -up DXA scans are recommended every 1 – 2 years to monitor BMD
response of pharmacological intervention. Patients with an inadequate
response, further bone loss or new fracture should be referred for further
investigation and management.
Active physical programs should be prescribed and monitored to keep the
patient’s fitness to a maximum.
Interpretation of BMD
World Health Organization Diagnostic Criteria
for women without fragility fractures3
Diagnosis
BMD criteria
Normal
BMD value within 1 SD of the young adult mean
Osteopenia
BMD value between -1 SD and -2.5 SD below the young
adult mean
Osteoporosis
BMD value at least -2.5 SD below the young adult mean
BMD = bone mineral density; SD = standard deviation
Conclusion
Osteoporosis is a common disease with a significant mortality and morbidity.
The orthopaedic surgeon has an important role in identifying patients at risk
and instituting or referring the patient for cost effective investigation,
prevention and management to decrease the burden of osteoporosis,
decrease fracture risk and improve the quality of life of many patients.
Patient with Risk Factors
-low trauma fracture, regular steroid use, family
history of osteoporosis, regular/heavy alcohol use,
anti-seizure medicine, smoking, small body frame,
poor calcium intake, malabsorption syndrome.
Patient with Risk
Factors + Fragility
Fracture
Treat the fracture
Exclude secondary causes
(ESR, full blood count, serum Ca, alkaline
phosphatase, creatinine, phosphate,albumin,
protein electrophoresis, sex hormones)
Secondary cause
No secondary cause
BMD
Confirm secondary
cause and treat
T-score -1 to 1.5 with risk
factors
Non-pharmacological
Fitness
Diet
Follow-up
1 – 2 yearly
T-score <-1.5 to -2.5
with fracture or other
major risk factors
(e.g. glucocorticoids)
T-score <-2.5
with no fracture
Consider active
treatment
Monitor
1 – 2 yearly
Identification and prevention of osteoporosis is still the top priority. The major
problem for orthopaedic surgeons is the elderly with fragility fractures due to
osteoporosis and possible co-morbid conditions Identifying, diagnosing and
monitoring the treatment of osteoporosis by a full radiologic, densitometric
and biochemical evaluation is mandatory. The orthopaedic surgeon must look
past the myths of osteoporosis and apart from managing fragility fractures,
treat the patient as a whole to maintain bone mass and quality of life.
References
1 Consensus Development Conference, Prophylaxis and treatment of
osteoporosis. Am J Med. 1991;90:107-110
2 Facts and statistics about osteoporosis and its impact. Accessed from
www.osteofound.org/press_centre/fact_sheethtml on 18/07/2005
3 Guidelines for preclinical evaluation and clinical trials in osteoporosis
Geneva: WHO: 1998:59l
4 Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA:
Mortality after all major types of osteoporotic fracture in men and
women: A observational study. Lancet 1999;353:878-882
5 Black DM, Cummings SR, Karpt DB, et al: Randomised trial of effect of
alendronate on risk of fracture in women with existing vertebral
fractures: Fracture Intervention Trial Research Group Lancet
1996;348:1535-1541
6 Bouxsein ML, Kaufman J, et al Recommendations for Optimal Care of
the Osteoporotic Fracture Patient to Reduce the Risk of Future
Fracture J Am Acad Orthop Surg 2004;12:385-395
7 J Kaufman “The role and responsibility of the orthopaedic surgeon in
treating osteoporosis” at the 6th Congress of the European Federation
of national Associations of Orthopaedics and Traumatology, Helsinki,
Finland, June 4-10
8 Brown JP, Josse RG for the Scientific Advisory Council of the
Osteoporosis Society of Canada. 2002 Clinical practice guidelines for
the diagnosis and management of osteoporosis in Canada
9 Osteoporosis Clinical Guidelines South African Medical Association
and NOFSA Working Group. S Afr Med J 2000, 90. (9): 905-944
10 National Osteoporosis Foundation; Physician’s Guide to the Prevention
and Treatment of Osteoporosis. Washington, DC: National
Osteoporosis Foundation, 2003